Until the early part of the twentieth century, practically all physicians in the United States and elsewhere were primary care physicians, not specialists. This changed dramatically in all developed countries over the remainder of that century, so that at present, over 75% of all American doctors specialize in fields like surgery, cardiology, dermatology, urology, and oncology. Specialization in Europe also grew over time, but at a much slower rate than in the United States, the result being that European medicine is practiced with relatively fewer specialists compared to generalists.
The growth in medical specialists over time is largely explained by the general economic theory of specialization and the division of labor. Medical specialization becomes more attractive when spending on medical care increases since a bigger market for medical care provides even highly specialized physicians a large enough market for their services. This conclusion is an application of Adam Smith’s famous dictum in the Wealth of Nations that the division of labor is influenced by the extent of the market. Since medical spending per person and in the aggregate is much higher in the United States than other countries, it is no surprise that American specialization is much greater than elsewhere.
The great advances in medical knowledge, especially since the 1950s, also contributed to the growth in specialization. For it takes expensive and very time-consuming investments by young doctors as medical residents and in other ways to gain command of the extensive information needed to practice modern surgery, oncology, cardiology, and other specialties. Specialization also increases when the ability to coordinate different specialists and generalists improves. That has been happening in the medical field with the growth of online records that transfers information among different specialists and generalists who are caring for the same patients, and especially with the development of group practices and medical centers that enable patients to visit different specialists and generalists in the same suite of offices or in nearby buildings.
Levels of compensation, as determined by the forces of supply and demand filtered through government policies and private insurance companies, also determine the degree and types of specialization. For medical students respond to the financial returns and other conditions found in different specialties and in general medical practice. In one important respect at least, as Posner indicates, the health care changes enacted into law by Obama will increase the demand for primary care physicians by providing subsidized medical insurance for over 30 million generally younger persons who have been without medical insurance. Young people primarily use medical care to treat the flu and other respiratory diseases, to receive general medical checkups, to treat the effects of accidents, and to get help on other medical problems that mainly involve visits, at least initially, to primary care physicians. However, the further growth over time in spending on the elderly through Medicare and private insurance will primarily increase the demand for cardiologists, oncologists, surgeons, and specialists in geriatric medicine.
Is there a “shortage” of primary care physicians relative to “shortages” of specialists? I am doubtful for several reasons. Many specialists also engage in general medical practice, especially among patients who initially come to them for specialized treatment, but who then receive medical care for medical problems that are the main business of general practitioners. This ability of specialists to also practice general medicine enables specialists to fill out their working days, and also tends to prevent any excess demand for primary care physicians from getting too large relative to the demand for specialists.
If this conclusion is correct, waiting times to get appointments for visits to general practitioners should not be significantly longer than the waiting times to get appointments to specialists. A 2009 survey by Merritt Hawkins, a healthcare consulting company, estimates willingness to take Medicaid patients and also waiting times in 15 metropolitan areas for cardiologists, dermatologists, orthopedic surgeons, obstetricians/gynecologists, and family practitioners. Willingness of general practitioners to take Medicaid patients is not lower than that of these specialists, with the exception of cardiologists.
While waiting times vary greatly among these areas, they are not systematically longer for family medicine than for the specialties surveyed. Waiting times are much longer for the Boston area than in any other area perhaps because of the vast expansion in health coverage in Massachusetts during the past decade. The wait times averaged over all the metropolitan areas vary by category of medical practice, from 16 days in cardiology to 28 days in obstetrics/gynecology. Family practice is in the middle at about 20 days. There appears to be a tendency for the categories with generally more urgent needs, like cardiology, to have the shortest waits, and those with the least urgent needs, like dermatology and obstetrics, to have the longest waits.
Much more evidence is needed on both wait times and salaries to reach definitive conclusions about shortages in different medical markets. However, these waiting time data suggest that substitution on the part of patients between family practitioners and specialists who can offer similar services, and arbitrage among medical students in deciding which fields to enter, prevents the development of particularly large “shortage” of general practice physicians.
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Posted by: MBT Sale | 07/09/2011 at 07:59 AM
First post. I'm a 77 year old retired neuroradiologist who never understood physics and yet in middle life learned to interpret CT and MR studies. Med schools agree with other posters and are de-emphasizing science.
A solution to the shortage of primary care physicians is to recognize the expertise of "physician assistants" who have ready access to diagnostic services. Physicians will be available when needed for referral and also routinely review case histories.
We could then reduce the number of physicians, provide good care and lower the cost.
This is, of course, already happening but should be encouraged dramatically.
Posted by: Barry Gerald | 07/09/2011 at 11:35 AM
Barry -- Yep! It does seem a team approach is and will replace docs as gods with underpaid nurses scurrying abound doing most of the work.
The military has long benefited from such an approach. When I was in, for most things we'd see a "medic" who was a draftee of six weeks training and real docs when the need presented. Not perfect but, as you say the trend toward physician assistants and nurse practitioners has got to be a part of any solution......... ie cost containment.
Posted by: Jack | 07/09/2011 at 06:51 PM
Jack,
The Insurance companies are gearing up to buy physician groups. That should work out really well!!!
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Posted by: Jim | 07/10/2011 at 12:03 PM
I dare anybody in this forum to become a primary care physician. Every honky tonk in this country feels entitled to attack anybody who has worked and study their heads off to get where they are and expect to have the same consideration.
Primary care physicians, especially family medicine, are overworked, underpaid and under recognized and are now expected to support pay cuts and extra work?????? give me a break!!! The national yearly salary for a family physician is 170,000 $ sounds like a lot right?...wrong!!!! take away taxes, malpractice insurances and legal issues, office expenses, and the ever so pleasing small print loop holes and you end up with less than your average bachelor degree educated corporate worker. Don't belive me? ask your local doc. And on top of this compare it with the national average for cardiology, or spine surgery which is over half a million dollars per year. talk about discrepancy. People are not gonna be happy until physicians are living in a trailer and collecting food stamps, but they still expect for them to take care of their most important thing which is their health 24 hours a day/7 days a wek. We are very close to saying "no more".
Posted by: Bill Rogers | 07/10/2011 at 12:31 PM
Amen to Bill Rogers. The difference between a car mechanic and a physician is that the physician has to make repairs while the unit is running.
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Does the scope of healthcare bills must deal with this issue? There must be greater problem in which lead to this scarcity on primary care physicians.
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